Surgical Management of Peripheral Vein Thrombophlebitis in the Upper Extremity

PURPOSE: Peripheral vein thrombophlebitis has a reported overall incidence ranging from 20% to 80%. Thrombophlebitis can progress despite antibiotic therapy to become a challenging clinical problem requiring surgical intervention. There is currently no consensus on its optimal management. We reviewed our experience of surgical intervention with analyses of the indications for intervention, descriptions of the surgical procedures, and outcomes. We aimed to provide guidance on the management of this potentially serious complication. METHODS: This is a retrospective review of 51 patients with thrombophlebitis refractory to conservative management between January 2017 and August 2020. RESULTS: Analyses revealed a high prevalence of comorbidities, including diabetes mellitus, malignancy, and chronic kidney disease. A total of 60% of patients had concurrent bacteremia, and the decision to operate had a low threshold in the presence of these factors. On exploration, 80% of patients had intraluminal thrombus, 47% had intraluminal pus, and 29% had pus beyond the veins or extending proximally. The surgical approach employed in 98% of patients involved an extensile incision in those with several morbidity factors (diabetes mellitus, chronic kidney disease, or bacteremia). One patient presented with severe clinical signs of local infection, and on exploration, there was intraluminal pus and thrombus up to 10 cm. A novel technique of a minimally invasive approach of intermittent stab incisions was employed in a young and healthy patient without comorbidities. CONCLUSIONS: We developed an algorithm to guide the indications for intervention and surgical approach to thrombophlebitis. The threshold for intervening surgically should be lowered by the presence of comorbidities. The failure of antibiotics to resolve the clinical signs of infection or the suspicion of abscess formation should mandate intervention. Thrombosed sections of the vein should be ligated proximally and distally and excised and surrounding collections of pus drained. Delayed secondary wound closure is usual. Stab incisions may limit surgical dissection and subsequent scarring in less severe cases. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.